Barriers to pregnancy prevention for adolescents in rural Haiti: perceptions of healthcare providers.

BACKGROUND: Little is known about healthcare providers' (HCPs) contraceptive views for adolescents in Haiti, who experience high rates of unintended pregnancy. We sought to describe HCPs' perspectives on barriers and facilitators to contraceptive care delivery in rural Haiti. METHODS: We conducted a cross-sectional survey and qualitative interviews with HCPs in two rural communities in Haiti from 08/2021-03/2022. We assessed demographics, clinical practice behaviors and explored contraception perspectives according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control (e.g., people's perceptions of their ability to perform a given behavior, barriers and facilitators of a behavior).15-17 We used descriptive statistics to report proportions and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through thematic inductive coding and team debriefing. RESULTS: Among 58 respondents, 90% (n = 52) were female and 53% (n = 31) were nurses. Most reported always (n = 16, 28%) or very often (n = 21, 36%) obtaining a sexual history for adolescents. A majority agreed/strongly agreed that clinicians should discuss pregnancy prevention (n = 45, 78%), high-risk sexual behaviors (n = 40, 69%), and should prescribe contraception (n = 41, 71%) to adolescents. The most frequently cited provider-level barriers (i.e., significant or somewhat of a barrier) included insufficient contraception knowledge (n = 44, 77%) and time (n = 37, 64%). HCPs were concerned about barriers at the patient-level (e.g. adolescents' fear of parental notification [n = 37, 64%], adolescents will give inaccurate information about sexual behaviors [n = 25, 43%]) and system-level (e.g. resistance to providing care from administration [n = 33, 57%]). In interviews (n = 17), HCPs generally supported contraception care for adolescents. Many HCPs echoed our quantitative findings on concerns about privacy and confidentiality. HCPs reported concerns about lack of contraception education leading to misconceptions, and community and parental judgement. HCPs expressed interest in further contraception training and resources and noted the importance of providing youth-friendly contraceptive care. CONCLUSIONS: While HCPs support contraceptive care, we identified actionable barriers to improve care for adolescents in rural Haiti. Future efforts should include increasing HCP knowledge and training, community and parent coalition building to increase contraception support and offering youth-friendly contraceptive care to offset risk for related adverse health outcomes in adolescents in rural Haiti.

Sexual behaviors, contraception use and barriers among adolescents and young adults in rural Haiti.

BACKGROUND: Adolescents and young adults (AYAs) in Haiti experience a high unintended pregnancy rate, in part due to unmet contraception needs. Little is known about AYA opinions of and experiences with contraception that may explain remaining gaps in coverage. We aimed to describe barriers and facilitators to contraception use among AYAs in Haiti. METHODS: We conducted a cross-sectional survey and semi-structured qualitative interviews with a convenience sample of AYA females aged 14-24 in two rural communities in Haiti. The survey and semi-structured interviews assessed demographics, sexual health and pregnancy prevention behaviors and explored contraception opinions and experiences according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control. We used descriptive statistics to report means and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through inductive coding and team debriefing. RESULTS: Among 200 survey respondents, 94% reported any past vaginal sexual activity, and 43% reported ever being pregnant. A large majority were trying to avoid pregnancy (75%). At last sexual activity, 127 (64%) reported use of any contraceptive method; Among them, condoms were the most common method (80%). Among those with previous condom use, most reported use less than half the time (55%). AYAs were concerned about parental approval of birth control use (42%) and that their friends might think they are looking for sex (29%). About one-third felt uncomfortable going to a clinic to ask for birth control. In interviews, AYAs desired pregnancy prevention but frequently noted concerns about privacy and parental, community and healthcare provider judgement for seeking care for reproductive health needs. AYAs also noted a lack of contraception knowledge, evident by frequent misconceptions and associated fears. CONCLUSION: Among AYAs in rural Haiti, a large majority were sexually active and desire pregnancy avoidance, but few were using effective contraception due to numerous concerns, including privacy and fear of judgement. Future efforts should address these identified concerns to prevent unintended pregnancy and improve maternal and reproductive health outcomes in this population.

Menstrual health among adolescents and young adults in rural Haiti.

BACKGROUND: Adolescent and young adult (AYA) females in low- and middle-income countries often face disparities in menstrual health (MH). Poor MH and lack of sexual and reproductive health education leads to school absenteeism, increasing risk for adverse psychosocial and educational outcomes. Further, disasters (e.g., earthquakes) are linked with unsafe living environments and sanitation facilities for women. We sought to describe MH perspectives and practices among AYAs in rural Haiti. METHODS: We conducted a cross-sectional survey in two rural communities in Haiti. AYA females aged 14-24 years completed questions on demographics, the Menstrual Practice Needs Scale (36 items; MPNS-36) and the Menstrual Practices Questionnaire (4 items). We performed descriptive statistics and Chi square or Fisher's Exact tests to compare responses among sub-groups. RESULTS: Among 200 respondents, the median age was 20 years (IQR 17-22). 51% (95% CI 44%, 58%; 102/200) were currently attending school at least 3 days/week and 97% (94%, 99%; 193/200) were not married. According to the MPNS-36, 68% (62%, 74%; 136/200) of participants had unmet MH needs. Seventy-one (77%) reused some of their menstrual materials during their last menstruation. During their last menstruation, 44% (37%, 50%; 87/200) reported they often or always skipped school because they had their menses, and 31% (25%, 37%; 62/200) sometimes skipped. Many felt always or often worried that someone or something would harm them while they were changing their menstrual materials at home and at school. CONCLUSIONS: Among AYAs in rural Haiti, three-quarters reported menses-related school absenteeism and two-thirds had unmet MH needs. AYA females often lacked a safe environment to change their menstrual materials. Given recent disasters in Haiti, (August 2021 earthquake), safe environments for MH are critically needed to offset risk for poor psychosocial and health outcomes. Future efforts to improve MH among AYAs in Haiti are needed to ensure access to MH resources and school attendance.

Adolescents and young adult (AYA) females in low- and middle-income countries can often lack adequate access to materials to manage their menstruation, in addition to safe spaces to change those materials. This lack of access, in addition to low levels of reproductive health education, can cause AYAs to miss school, leading to increased risk of worse psychosocial and educational outcomes. In addition, disasters (e.g., earthquakes) are linked with unsafe living environments and sanitation facilities for women. We sought to describe AYA menstrual practices and perspectives on menstrual hygiene in rural Haiti. In two rural communities in Haiti, AYA females aged 14­24 years answered questions on their demographics and menstrual hygiene practices and environments. Two-thirds of AYAs had unmet menstrual hygiene needs and three-quarters reported they skipped school (with any frequency) due to their menses. Further, more than half worried that something or someone would harm them while they were changing their menstrual materials at home and at school. AYA females often lacked a safe environment to change their menstrual materials. Given recent disasters and political unrest in Haiti, (August 2021 earthquake), it is important to improve menstrual hygiene in these LMICs to ensure safe enviornments for managing menstruation and school attendance and ultimately improve psychosocial and health outcomes.

Acute Care Utilization and Health Care Expenditures in Medicaid-Enrolled Children.

OBJECTIVES: Although recent health care reform efforts have focused on minimizing high cost health care utilization, the relationship between acute care use and health care expenditures among certain vulnerable populations such as Medicaid-insured children remains poorly understood. We sought to evaluate the association between acute care utilization and health care expenditures and to identify characteristics associated with high spending. METHODS: We performed a retrospective cohort study of Medicaid-enrolled children 1-21 years old from 1/1/2016 to 12/31/2016. Children were categorized by acute care use (including emergency department and urgent care visits) as 0, 1, 2, 3, and 4 or more visits. Our main outcomes were annualized spending, total per-member-per-year spending, and acute care-related per-member-per-year spending. RESULTS: There were 5.1 million Medicaid-enrolled children that comprised the study cohort, accounting for US $32.6 billion in total spending. Children with 4 or more acute care visits were more likely to be younger than 2 years or older than 14 years, female, and have a chronic condition. Children with 4 or more acute care visits consisted of only 4% of the cohort but accounted for 15% (US $4.7 billion) of the total spending. Increasing acute care visits were associated with increasing total annualized spending in adjusted analyses (P < 0.001). This association was disproportionately observed in older age groups and children without chronic medical conditions. CONCLUSIONS: Medicaid spending for children increases with increasing acute care use; this trend was disproportionately observed in older age groups and children without chronic medical conditions. Improved understanding of factors contributing to frequent acute care utilization and disproportionate spending is needed to potentially reduce unnecessary health care costs in these pediatric populations.

Justice System Involvement Among Adolescents in the Emergency Department.

OBJECTIVE: To assess justice system involvement among adolescents in the pediatric emergency department and identify associations with risk and protective factors. STUDY DESIGN: We conducted a cross-sectional, computerized survey of adolescents to assess for personal, justice system involvement, and nonhousehold justice system involvement (ie, important people outside of household). We assessed sexual behaviors, violent behaviors, substance use, school suspension/expulsion, parental supportiveness, and participant mood (score <70 indicates psychological distress). We compared differences between groups using the χ2 tests, Fisher exact tests, t tests, and performed multivariable logistic regression analyses. RESULTS: We enrolled 191 adolescents (mean age 16.1 years, 61% female). Most (68%) reported justice system involvement: personal (13%), household (42%), and nonhousehold (40%). Nearly one-half (47%) were sexually active and 50% reported school suspension/expulsion. The mean score for mood was 70.1 (SD 18); adolescents with justice system involvement had had lower mood scores (68 vs 74, P = .03) compared with those without justice system involvement. In a multivariable model, school expulsion/suspension was significantly associated with reporting any justice system involvement (OR 10.4; 95% CI 4.8-22.4). CONCLUSIONS: We identified the pediatric emergency department as a novel location to reach adolescents at risk for poor health outcomes associated with justice system involvement. Future work should assess which health promotion interventions and supports are desired among these adolescents and families.

Sexually Transmitted Infection Diagnoses at Children's Hospitals During COVID-19.

OBJECTIVES: COVID-19 mitigation strategies resulted in changes in health care access and utilization, which could negatively impact adolescents at risk for sexually transmitted infections (STIs). We evaluated changes in STI diagnoses during adolescent visits at children's hospitals during COVID-19. METHODS: We conducted a retrospective cohort study using the Pediatric Health Information System database comparing adolescent (11-18 years) hospital visits with an STI diagnosis by International Classification of Diseases, 10th revision, code during COVID-19 (2020) to pre-COVID-19 (2017-2019). Data were divided into spring (March 15-May 31), summer (June 1-August 31), and fall (September 1-December 31). Median weekly visits and patient characteristics were compared using median regression. RESULTS: Of 2 747 135 adolescent encounters, there were 10 941 encounters with an STI diagnosis from 44 children's hospitals in 2020. There was a decrease in overall median weekly visits for STIs in spring during COVID-19 (n = -18.6%, P = .001) and an increase in overall visits in summer (11%, P = .002) during COVID-19. There were significant increases in inpatient median weekly visits for STIs in summer (30%, P = .001) and fall (27%, P = .003) during COVID-19. We found increases in Neisseria gonorrhoeae (50%, P < .001) and other STI diagnoses (defined as other or unspecified STI by International Classification of Diseases, 10th revision, code; 38%, P = .040) in fall COVID-19 (2020), and a decrease in pelvic inflammatory disease (-28%, P = .032) in spring COVID-19 (2020). CONCLUSIONS: We found increases in median weekly adolescent inpatient visits with an STI diagnosis in summer and fall COVID-19 (2020). These findings were likely partially driven by changes in behaviors or health care access. Further work is needed to improve STI care and thus potentially improve related health outcomes.

Adolescent Relationship Abuse Among Hospitalized Adolescents.

OBJECTIVE: We assessed adolescent relationship abuse (ARA) prevalence and ARA intervention acceptability and perceived benefit among hospitalized adolescents and young adults (AYA). METHODS: This was a planned secondary analysis of a cross-sectional survey exploring sexual and reproductive health among a convenience sample of AYA (14-25 years) hospitalized in medical/surgical units at two Midwest children's hospitals. Survey items assessed history of dating, lifetime prevalence of four types of ARA (physical abuse, sexual abuse, reproductive coercion, sexual exploitation), and demographics. RESULTS: Among 324 participants, 72.5% reported dating and, among those with history of dating, 17% reported one or more types of ARA. ARA was more common among those who reported foregone health care in the preceding 12 months. There was no difference in likelihood of dating and ARA between those with and without a chronic health condition. Approximately half felt it is helpful for clinicians to discuss dating relationships with adolescents (58.6%) and acceptable to do this during a hospitalization (50.6%). Conversations with clinicians about dating relationships were more likely to be reported helpful by those who had dated (63.9% reporting dating vs 50.6% not reporting dating, P 0.04) and those who reported prior ARA (79.5% reporting ARA vs 60.4% not reporting ARA, P 0.02). CONCLUSIONS: Hospitalization may represent a unique opportunity to support healthy AYA dating relationships. Further work is needed to further explore acceptability and feasibility of such interventions.

Substance Use Emergency Department Visits Among Youths With Chronic Conditions During COVID-19.

Importance: Pediatric emergency department (ED) visits for substance use (SU) increased during COVID-19. Better understanding of trends associated with SU ED visits among youths with a chronic medical condition (CMC) is needed to target SU screening, prevention, and intervention efforts in this population. Objective: To describe trends in pediatric SU ED visits before and during COVID-19 among youths in the US with and without CMCs and by race and ethnicity. Design, Setting, and Participants: In this cohort study, data were obtained from 47 US children's hospital EDs in the Pediatric Health Information System (PHIS) between March 1, 2018, and March 1, 2022. The cohort included patients aged 10 to 18 years. Data analysis occurred from November 2022 to February 2023. Exposures: ED visit occurrence before or during the COVID-19 pandemic and with or without the presence of a CMC. CMCs included chronic conditions (CCs) and complex CCs (CCCs). Main Outcomes and Measures: The primary outcome was the number of visits for an SU diagnosis based on diagnostic codes for youths with and without CMCs. Trends were assessed using logistic regression, adjusting for covariates and center effect. Results: The sample included 3 722 553 ED visits from March 1, 2018, to March 1, 2022 (1 932 258 aged 14-18 years [51.9%]; 1 969 718 female [52.9%]; 961 121 Hispanic [25.8%]; 977 097 non-Hispanic Black [26.2%]; 1 473 656 non-Hispanic White [39.6%]). Of all visits, 1 016 913 (27.3%) were youths with CCs and 367 934 (9.9%) were youths with CCCs. Youth SU ED visits increased for all groups during COVID-19. The SU ED visits increased by 23% for youths with CCs (21 357 visits [4.0%] to 23 606 visits [4.9%]), by 26% for youths with CCCs (3594 visits [1.9%] to 4244 visits [2.4%]), and by 50% for youths without CCs (4997 visits [0.4%] to 5607 visits [0.6%]). Furthermore, compared with youths without CCs, youths with CCs had consistently larger odds of SU than the other groups before COVID-19 (adjusted odds ratio, 9.74; 99% CI, 9.35-10.15) and during COVID-19 (adjusted odds ratio, 8.58; 99% CI, 8.25-8.92). The interaction between race and ethnicity and CMCs was significant (P for interaction < .001). Conclusions and Relevance: The findings of this cohort study suggest that providing SU services to all youths during times of societal crises is critical, but particularly for youths with CMCs who experience higher potential health impacts from SU given their medical concerns.

Feasibility of a Contraception Intervention for Hospitalized Adolescents and Young Adults.

OBJECTIVES: Unintended pregnancy in adolescents and young adults (AYAs) is linked with negative outcomes. We sought to evaluate the feasibility, acceptability, and preliminary efficacy of a contraception intervention in the pediatric hospital. METHODS: We conducted a pilot study of hospitalized AYA females aged 14 to 21 years who reported past or anticipated sexual activity. A health educator offered a tablet-based intervention to provide contraception education and medications, if desired. We assessed feasibility (ie, intervention completion, duration, disruption to care), acceptability (ie, proportion rating as acceptable or satisfactory) among AYAs, parents or guardians, and healthcare providers, as well as preliminary efficacy (eg, contraception uptake) at enrollment and 3-month follow up. RESULTS: We enrolled 25 AYA participants; mean age was 16.4 ± 1.5 years. The intervention demonstrated high feasibility as all enrolled participants (n = 25, 100%) completed the intervention and median intervention duration was 32 (interquartile range 25-45) minutes. Among 11 nurses, 82% (n = 9) reported the intervention was not at all or minimally disruptive to their workflow. All AYAs were very or somewhat satisfied with the intervention and 88% (n = 7) of 8 parents and guardians surveyed felt it was acceptable for the educator to meet privately with their child. Eleven participants (44%) started hormonal contraception, most commonly the subdermal implant (n = 7, 64%), and 23 (92%) received condoms. CONCLUSIONS: Our findings support the feasibility and acceptability of our contraception intervention in the pediatric hospital resulting in contraception uptake among AYAs. Efforts to expand access to contraception are important to reduce unintended pregnancy, especially as restrictions to abortion are increasing in some states.

Understanding the Sexual and Reproductive Health Needs of Hospitalized Adolescent Males.

OBJECTIVES: To describe sexual behaviors and acceptability of receiving sexual and reproductive health (SRH) services among hospitalized adolescent males. METHODS: We performed a cross-sectional survey of hospitalized adolescents. Eligible participants were males aged 14 to 20 years admitted at 2 academic medical centers. Outcome measures included reported healthcare utilization, sexual health behaviors (eg, sexual activity), contraception use, and acceptability of SRH discussions during a hospitalization. RESULTS: Among 145 participants, 42% reported a history of vaginal sex, 27% current sexual activity, 12% early sexual debut, and 22% 4 or more prior sexual partners. At last sex, condom use was reported by 63% and use of reversible contraception by 36%. Nearly half (45%) agreed that hospital-based SRH discussions were acceptable, particularly among those with history of sexual activity (P < .01). Some (12%) reported they had not accessed care in the past year when they felt they should. CONCLUSIONS: Hospitalized males in our study had similar rates of sexual activity as compared with the general population but had higher rates of early sexual debut and number of prior partners, which are independently linked with negative sexual health outcomes (eg, sexually transmitted infections). Our participants found SRH discussions to be generally acceptable. These findings reveal opportunities to screen for unmet SRH needs and provide SRH education and services for adolescent males in the hospital.

Substance Use Disorder Visits Among Adolescents at Children's Hospitals During COVID-19.

PURPOSE: To assess changes in adolescent visits with substance use disorders (SUDs) at children's hospitals during COVID-19. METHODS: We conducted a retrospective cohort study of adolescents (11-18 years) with SUD diagnoses during a hospital visit in the Pediatric Health Information System. Study periods were defined as spring (03/15-05/31), summer (06/01-08/31), and fall (09/01-12/31), pre-COVID-19 (2017-2019), or during COVID-19 (2020). We summarized the change in weekly median visits and interquartile range (IQR) by characteristics and compared between the two periods (e.g., spring pre-COVID-19 [3/15-05/31/2017-2019] versus spring COVID-19 [3/15-05/31/2020]) using median regression. RESULTS: There were 42,979 SUD visits (10,697 COVID-19; 32,282 pre-COVID-19) and 256 annual weekly median adolescent SUD visits [IQR 235, 280] pre-COVID-19 and 268 [IQR 245, 278] during COVID-19. The median number of weekly SUD visits increased by 14.3% during summer COVID-19 (median visits, [IQR]: 272 [268, 278]) compared to pre-COVID-19 (median visits: 237, IQR [216, 249]; p < .001) but did not significantly differ in spring (p = .091) or fall (p = .65) COVID-19. DISCUSSION: Our findings suggest increased problematic adolescent substance use during summer COVID-19. Efforts to increase the identification and treatment of adolescent SUDs remain critical.

Trends in Adolescent Cannabis-Related Hospitalizations by State Legalization Laws, 2008-2019.

PURPOSE: Adolescent cannabis use is associated with adverse health outcomes. The impact of cannabis legalization on adolescent cannabis-related hospitalizations remains unknown. We sought to assess whether state cannabis legalization is associated with adolescent cannabis-related hospitalizations. METHODS: We conducted a retrospective cohort study of adolescent (11-17 years) hospitalizations at children's hospitals between January 1, 2008 and December 31, 2019 using the Inpatient Essentials database. We investigated differences in adolescent cannabis-related diagnosis during a hospitalization by state cannabis legalization status, including states with no legal use to medical cannabis laws (MCLs) and states with MCLs to nonmedical (>21 years old) cannabis laws (NMCLs). RESULTS: Of 1,898,432 adolescent hospitalizations in 18 states and Washington, DC, there were 37,562 (2%) hospitalizations with a cannabis-related diagnosis, with 8,457 (23%) in states with no legal use, 20,444 (54%) in MCL states, and 8,661 (23%) in NMCL states. There was an increase in adjusted odds of a cannabis-related hospitalization in MCL (odds ratio 1.05, 95% confidence interval 1.04-1.06) and NMCL states (odds ratio 1.03, 95% confidence interval 1.02-1.03) between 2008 and 2019. Characteristics associated with the greatest increase in adjusted odds of a cannabis-related hospitalization postpolicy change included adolescents without an underlying mental health or other substance use disorder in MCL and NMCL states (p < .001) and younger age in NMCL states (13 vs. 16 and 17 years old, p = .02 and p = .02). CONCLUSIONS: Cannabis-related adolescent hospitalizations at children's hospitals are increasing, with a disproportionate increase postlegalization in states with NMCLs. Interventions are warranted to increase cannabis use identification and treatment among at-risk adolescents in the hospital-based setting.

Safety Events in Children's Hospitals During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. Our objective was to compare pediatric hospitalization safety events during the pandemic versus previous years. METHODS: In this retrospective cohort study of hospitalizations in the Pediatric Health Information System, we compared Pediatric Quality Indicator (PDI) rates from March 15 to May 31, 2017-2019 (pre-COVID-19), with those from March 15 to May 31, 2020 (during COVID-19). Generalized linear mixed-effects models with adjustment for patient characteristics (eg, diagnosis, clinical severity) were used. RESULTS: There were 399 113 discharges pre-COVID-19 and 88 140 during COVID-19. Unadjusted PDI rates were higher during versus pre-COVID-19 for overall PDIs (6.39 vs 5.05; P < .001). In adjusted analyses, odds of postoperative sepsis were higher during COVID-19 versus pre-COVID-19 (adjusted odds ratio 1.28 [95% confidence interval 1.04-1.56]). The remainder of the PDIs did not have increased adjusted odds during compared with pre-COVID-19. CONCLUSIONS: Postoperative sepsis rates increased among children hospitalized during COVID-19. Efforts are needed to improve safety of postoperative care for hospitalized children.

Self-reported and Documented Substance Use Among Adolescents in the Pediatric Hospital.

BACKGROUND AND OBJECTIVES: Adolescent substance use is associated with numerous adverse health outcomes. A hospitalization represents an opportunity to identify and address substance use. We sought to describe self-reported and documented substance use among hospitalized adolescents. METHODS: We conducted a cross-sectional survey of adolescents aged 14 to 18 years old admitted to two pediatric hospitals between August 2019 and March 2020. Using previously validated questions, we assessed the proportion of adolescents reporting ever, monthly, and weekly use of alcohol, marijuana, tobacco, electronic cigarettes, and other illicit drugs and nonmedical use of prescription medications. We reviewed medical records for substance use documentation. RESULTS: Among 306 respondents, 57% were older (16-18 years old), 53% were female, and 55% were of non-Hispanic white race and ethnicity. The most frequently reported substances ever used were alcohol (39%), marijuana (33%), and electronic cigarettes (31%); 104 (34%) respondents reported ever use of >1 substance. Compared with younger adolescents, those aged 16 to 18 years were more likely to report ever use of alcohol (29% vs 46%; P = .002), marijuana (22% vs 41%; P < .001), and ≥2 drugs (26% vs 40%; P = .009). A positive substance use history was rarely documented (11% of records reviewed), and concordance between documented and self-reported substance use was also rare. CONCLUSIONS: In this study of hospitalized adolescents, the most commonly reported substances used were alcohol, marijuana, and electronic cigarettes. Positive substance use documentation was rare and often discordant with self-reported substance use. Efforts to improve systematic screening for substance use and interventions for prevention and cessation in hospitalized adolescents are critically needed.

Sexual Health Behaviors and Pregnancy Risk Among Hospitalized Female Adolescents.

OBJECTIVES: To describe sexual health behaviors, contraceptive use, and pregnancy risk among hospitalized female adolescents. METHODS: We conducted a cross-sectional survey of hospitalized female patients aged 14 to 21 years at 2 academic medical centers to assess sexual health behaviors, contraceptive use, contraceptive counseling receipt, and factors associated with pregnancy complications (eg, diabetes, teratogenic exposure). We calculated the validated Pregnancy Risk Index (PRI) (number per 100 who will become pregnant in the next year). RESULTS: Among 177 participants (mean age 16 years, SD 1.5), 75 (43%) were sexually active. At last vaginal sex, 65% reported condom use; 49%, reversible contraception; and 12%, long-acting reversible contraception (LARC). Past-year contraceptive counseling was reported by 73% of sexually active female participants and was associated with increased use of reversible (P = .001) and dual contraception (P = .03) but not LARC (P = .24). The mean PRI among all participants was 4.75. Nearly three-quarters (73%) had a medical comorbidity or teratogenic exposure. Those with teratogenic medication use had the lowest PRI of 0.32 (P < .05), with 88% using reversible contraception and 31% using LARC. CONCLUSIONS: Hospitalized female adolescents had a PRI similar to that of adolescents in the general population. However, nearly three-quarters had a medical comorbidity and/or teratogenic exposure, which increased risk for pregnancy complications. Contraceptive counseling was associated with increased reversible and dual contraception use but not LARC use. Efforts to improve comprehensive contraceptive counseling, highlighting LARC, are critically needed in this population.

Barriers to Tobacco Cessation for Caregivers of Hospitalized Children: Perspectives of Pediatric Hospitalists.

OBJECTIVES: Secondhand smoke exposure is associated with adverse health outcomes in children, yet tobacco cessation efforts for caregivers of hospitalized children are lacking. We sought to explore pediatric hospitalists' attitudes and barriers to providing tobacco cessation for caregivers of hospitalized children. METHODS: We conducted a cross-sectional survey of pediatric hospitalists and fellows at 7 hospitals from November 1, 2018, to November 30, 2019. A 70-question anonymous survey was used to assess participants' perceptions of current practices, attitudes, and barriers to providing tobacco cessation support for caregivers of hospitalized children. We used descriptive statistics to summarize the data. RESULTS: Of 207 eligible participants, 100 responded (48%). A majority (79%) agreed that offering tobacco cessation counseling for caregivers is an important part of their role in caring for hospitalized children, but 79% never received tobacco cessation training. Only half of the participants were comfortable providing brief advice and few were comfortable prescribing nicotine replacement therapy. Identified barriers included lack of time (74%), perceived lack of interest from patients' caregivers (71%), and other medical conditions of the patient taking priority (70%). The majority of participants were interested in further training in tobacco cessation support. CONCLUSIONS: In this survey of 100 pediatric hospitalists, we found overall agreement that tobacco cessation support for caregivers of hospitalized children is important. However, most participants did not feel comfortable with provision of evidence-based counseling or pharmacotherapy because of identified barriers. Future work should target actionable barriers to improve provision of tobacco cessation support in this clinical setting.

Adolescent Reproductive Health Care: Views and Practices of Pediatric Hospitalists.

BACKGROUND AND OBJECTIVES: Many hospitalized adolescents are at increased risk for pregnancy complications due to an underlying medical condition, however sexual risk assessment is not consistently performed in this setting. While adolescents and their parents are supportive of sexual health discussion in the inpatient setting, a thorough understanding of factors that influence provision of this care among pediatric hospital physicians is lacking. This formative information is needed to facilitate efforts to improve and standardize clinical care provision. Our objective is to assess the frequency and factors that influence the provision of adolescent sexual and reproductive care by pediatric hospitalists. METHODS: We performed a cross-sectional computerized survey of hospitalists at 5 pediatric hospitals who cared for ≥1 adolescent (14-21 years old) in the past year. Sexual and reproductive care practices were assessed by using a 76-item novel survey informed by the theory of planned behavior. We used descriptive statistics to summarize the data. RESULTS: Sixty-eight pediatric hospitalists participated (49% response rate): 78% were women and 65% were aged <40 years. Most (69%) reported treating >46 adolescents annually, including many who are at an increased risk for pregnancy complications due to teratogenic medication use or a comorbid condition. A majority felt that sexual and reproductive services are appropriate, although many endorsed barriers, including concern about follow-up after emergency contraception (63%) and time constraints (53%). Most reported insufficient knowledge regarding contraception (59%), desired contraception education (57%), and were likely to increase contraceptive provision if provided education (63%). Hospitalists rarely provided condoms or referral for an intrauterine device. CONCLUSIONS: Pediatric hospitalists frequently care for adolescents who are at risk for pregnancy complications and generally agree that reproductive care is appropriate in the inpatient setting. With these findings, we highlight the critical need for effective comprehensive reproductive health service interventions that are tailored to address the numerous actionable barriers identified in this study.

Sexually Transmitted Infection Testing in Adolescents: Current Practices in the Hospital Setting.

PURPOSE: Adolescents are disproportionately affected by sexually transmitted infections (STIs), and evidence supports expanding sexual health services to the hospital setting. Because STI testing practices in the hospital setting are poorly understood, we sought to describe current STI testing practices among adolescents seen in children's hospitals. METHODS: We performed a retrospective analysis of adolescents (14-18 years old) from 45 children's hospitals in 2015-2016, excluding visits with a billing code for sexual abuse/assault. We calculated rates of STI testing and investigated differences in STI testing by patient and hospital characteristics using generalized linear mixed modeling. RESULTS: Of the 541,714 adolescent encounters, 59,158 (10.9%) underwent STI testing. After adjusting for demographic characteristics, those with an STI test were more likely to be female (adjusted odds ratio [aOR] 1.61; 95% confidence interval [CI] 1.58-1.64), of non-Hispanic black race/ethnicity (aOR 1.20; 95% CI 1.17-1.23), or from the lowest median household income quartile (aOR 1.21; 95% CI 1.17-1.24). There was substantial inter-hospital variation in adjusted rates of STI testing (3%-24%), but strong correlation was observed between STI testing rates in the ED and inpatient settings within individual hospitals (adjusted R2 .99). CONCLUSIONS: Only one in ten adolescents seen in children's hospitals underwent STI testing with wide variation in testing patterns across hospitals. There are critical opportunities to increase adolescent STI testing in this setting. Our findings highlight potential disparities in STI testing rates and patterns that warrant further exploration from the patient, provider, and health system perspective.